1. Susan Munroe, CEO, FfT Nicola Witcombe, IRCT (Torture Journal)
Freedom from Torture
Susan Munroe, CEO, FfT
Nicola Witcombe, IRCT (Torture Journal)

2. Torture Journal Vol.26(2) Measuring change and changing measures:
The development of a torture survivor specific measure of change
by Rebecca Horn and Andy Keefe

3. The Freedom from Torture (FfT) Measure of Clinical Change and Outcome (MOCCO): Development and Usage
About FfT
Why did FfT need to measure outcomes and develop their own tool?
What is MOCCO? 20 questions, scores
Key features of development
Challenges
What does MOCCO tell us?
What next for MOCCO?

4. About Freedom from Torture
UK-wide
5 centres
Largest torture rehabilitation centre in UK
£8M turnover £20M by 2025
150 staff plus volunteers
1300 survivors of torture / year

5. Why do FfT need to measure outcomes?
Funding
Quality Assurance
Governance
Regulation

6. Why did FfT need to develop our own tool?
Buy-in from staff
Nothing torture-specific ’off the shelf’

7. What is MOCCO? Measurement of Clinical Change & Outcome (MOCCO)
Client-rated outcome tool
Signs of distress and wellbeing - 20 questions
Positive & Negative impact of external factors
Quality of life in general

8. 20 questions (1) 1. Forgetting to do things 2. Feeling very sad
How much have the following things affected you over the last ONE WEEK?
1. Forgetting to do things
2. Feeling very sad
3. Unwanted memories
4. Feeling tense, anxious or nervous
5. Difficulty with sleeping
6. Nightmares

9. 20 Questions (2)
7. Realising or being told by other people that you have done something you cannot remember.
8. Feeling as if you were actually back in the distressing situation
9. Do distressing memories stop you from doing ordinary things?
10. Do you feel hopeless?

10. 20 Questions (3)
11. Do you feel that your soul is damaged? 12. Do you lose your temper over small things? 13. Do you feel ashamed? 14. Has talking with people felt like too much for you? 15. Have you been able to carry on with ordinary things when problems occur?

11. 20 questions (4) 16. Have you felt lonely?
17. Have you lost interest in things?
18. Have you made plans to end your life?
19. Have your feelings gone dead?
20. How much do you trust other people?

12. MOCCO scores Questions scored 0-3 Highest (worst) score 60
Lowest (best) score 0
minus (-) or plus (+) change in score represents improvement or deterioration
Applied on admission, 3 months, 6 months 12 months, then annually

13. Developing an outcome tool
Jaranson JM, Quiroga J. Evaluating the services of torture rehabilitation programmes: History and recommendations. Torture. 2011;21(2):
Mc Farlane CS, Kaplan I. Evidence-based psychological interventions for adults of torture and trauma: A 30-year review. Transcult Psychiatry Jul;49(3-4):
Patel N, Kellezi B, Williams C de C A. Psychological, social and welfare interventions for psychological health and well-being of torture survivors. Cochrane Database of Systematic Reviews 2014

14. What features are likely to help understand effectiveness?
How achieved
Consider context within which survivors live
Includes a section on clients’ wellbeing. Can record in brief what has the greatest impact (positive/negative)
Broad range of outcomes/those which have the greatest meaning for survivor
Outcomes included identified through ongoing discussion with clinicians and clients/what had greatest relevance for clients
Clinicians and other practitioners should be involved
Yes – concerning tool as well as how it was to be used

15. What features are likely to help understand effectiveness?
How achieved
Translators should be involved in the development of questions
Process of translation and back-translation
Sample size should be large enough to make comparisons where population heterogenous
Entire population at FfT’s 5 centres of adults engaged in individual therapy.
Outcomes should be studied over a sufficiently long period
MOCO used throughout contact with FfT

16. Challenges of developing our own tool
Expensive
Time-consuming
Translation
Testing - pilot

17. Challenges in using MOCCO
Client Database
Staff resistance
Staff training

19. What does MOCCO tell us?

20. % Modality Sessions
N=57284 sessions with recorded modality

21. Mean Centre Effect

22. OT Difference, by Torture Forms

23. What next for MOCCO? Change frequency of assessment
Improve clinician compliance (too many empty data fields and infrequent assessment)
External validation
Begin to use data as a performance measure for service development decision making